Nursing Elites

1. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reassure the client and encourage deep breathing.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.

2. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?

• A. White blood cell count of 15,000.
• B. Blood glucose level of 320 mg/dL.
• C. Sodium level of 145 mEq/L.
• D. Serum creatinine level of 1.0 mg/dL.

Correct answer: B

Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.

3. A client with asthma is experiencing wheezing. What is the nurse’s priority intervention?

• A. Administer a bronchodilator immediately.
• B. Increase the client's oxygen flow rate.
• C. Perform a chest x-ray to assess lung function.
• D. Place the client in a high Fowler’s position.

Correct answer: A

Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.

4. A client with hypertension is prescribed a thiazide diuretic. What dietary recommendation should the nurse make?

• A. Encourage a diet low in carbohydrates and fats.
• B. Avoid foods high in vitamin K, such as spinach and kale.
• C. Increase salt intake to prevent dehydration.
• D. Eat potassium-rich foods like bananas and oranges.

Correct answer: D

Rationale: The correct answer is D: 'Eat potassium-rich foods like bananas and oranges.' Thiazide diuretics can lead to potassium loss, so it is essential for clients to consume potassium-rich foods to maintain adequate levels. Choice A is incorrect because focusing solely on low carbohydrates and fats does not address the specific issue of potassium loss. Choice B is unrelated as vitamin K content is not a concern with thiazide diuretics. Choice C is incorrect as increasing salt intake would exacerbate hypertension and not prevent dehydration.

5. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?

• A. A migraine headache
• B. An infection from the puncture site
• C. Low blood sugar
• D. Spinal fluid leakage (post-lumbar puncture headache)

Correct answer: D

Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.

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